RM_StatsStudent InfoStudent InfoFirst NameLast NameHome Address Address Line 1 Address Line 2 City State or Region Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas, The Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, The Democratic Republic Of The Cook Islands Costa Rica Cote D'ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia, The Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and the McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iraq Iran Ireland Isle Of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Republic Of Kosovo Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia, The Former Yugoslav Republic Of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States Of Moldova, Republic Of Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territories Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and The Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Taiwan Tajikistan Tanzania, United Republic Of Thailand Timor-leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Country Zip Email *Phone #Current SchoolCurrent GradeDate of BirthGender Male Female EthnicityRaceTribal Affiliation (if applicable)Plans Beyond High SchoolWhat type of college or university do you plan to attend?Which semester and year do intend to enroll?What career are you interested in pursuing?What major will you study in college to prepare for this career?Need Help withPlease let us know how we can help you.I need help with: College Exam Information Admission Requirements Information Completing an admission application Financial aid information Completing the FAFSA (Financial Aid Application) Searching for scholarship information Completing a scholarship application College transition information College access for athlete’s information OtherFor AdvisorFIELDS ON THIS PAGE ARE FOR MEC ADVISORS ONLY. If you are not an MEC advisor, please skip this page.Are you an MEC Advisor? Yes No Academic InformationCurrent GPAHave you taken any college entrance exams (ACT, PSAT, SAT)?Have you taken dual enrollment community college classes?Have you taken any college preparation classes (Honors, AP, IB)?Have you been designated as a National Merit Finalist/SemiFinalist, National Hispanic Scholar or National Achievement Scholar?Household & Special Circumstances InformationFor financial aid and scholarship assistance, I will need to collect some information to give me an idea of your financial need and special circumstances. Is that ok with you?Family income rangeAre you eligible for the free or reduced lunch at your school?Is a female the head of your household?What was the highest level of education level completed by your father?What is your father’s current occupation?What is the highest level of education completed by your mother?What is your mother’s current occupation?Are you living on your own, homeless, in a foster home, or participating in the Youth on Their Own Program?Are you a person with disabilities?Follow-up Appointment Date:Follow-up Appointment Purpose and Action Items:Page 5 Note: It looks like JavaScript is disabled in your browser. Some elements of this form may require JavaScript to work properly. If you have trouble submitting the form, try enabling JavaScript momentarily and resubmit. JavaScript settings are usually found in Browser Settings or Browser Developer menu.
